Download Diabetes is a common chronic disease affecting millions of

Diabetes is a common chronic disease affecting millions of Americans. An
upward trend in the incidence of diabetes has occurred over the past thirty years
and it has been predicted that an ever-increasing percent of the population will
become diabetic, especially with the trend of increasing obesity in the United States
(US) (American Diabetes Association, 2011; Center for Disease Control and
Prevention (CDC) 2011; Agency for Healthcare Research and Quality (AHRQ), 2011).
In addition, an unequal distribution in the prevalence of diabetes by race ethnicity
and socio-economic status exists (ADA 2011;AHRQ, 2009). Use of evidence-based
clinical practice guidelines alone have underachieved targeted benchmarks, with an
even greater gap existing for vulnerable populations. Diabetes is a chronic and
complex disease requiring a comprehensive multifaceted approach to care to
improve processes and outcomes, and reduce healthcare disparities. Nurse
practitioners are often the providers for some of the most vulnerable people and
thus increase access to care for this population.
Background
Due to the co-morbidities and complications of diabetes, this chronic disease
has become the seventh leading cause of death in the United States (CDC, 2011).
The prevalence of diabetes in the US for adults eighteen years of age and older has
increased from 5.1 percent in 1997 to 9 percent as of January 2010 (CDC, 2011).
And, because of the increasing number of young to middle-aged adults who are
obese, and of minority race and ethnicity, this cohort group has resulted in an
increased number of persons who are diagnosed with type 2 diabetes as well as an
increase in the number of complications due to long-term diabetes (Smith, Drum,
Miernik, Fogelfeld, & Lipton, 2008). Poor people also experience disparities in
health leading to differences in morbidity and morality, and are twice as likely as
high-income people to report inabilities or delays in receiving needed healthcare
(AHRQ, 2010).
The AHRQ (2011) tracks outcomes and receipt of recommended services for
diabetes that decrease morbidity and mortality and reduce complications. From
2005-2008, the percent of diabetics who achieved HbgA1c, blood pressure and
cholesterol goals were 54, 58 and 65 percent respectively. Based on a benchmark
set by the top four top state achievers of 51.4 between the years 2002 to 2007, the
percent of diabetic patients who obtained follow-up of HbgA1c blood levels, dilated
eye exam and foot inspection decreased from 43.22 to 37.5 percent (AHRQ, 2010).
Additionally, in 2007, hospital admissions for short-term complications of diabetics
ages 18-44 did not achieve the benchmark of 37.8 percent, having increased from
55.2 % in 2004 to 59.9% in 2007 (AHRQ, 2010).
The estimated cost for the care of diabetic patients in 2007 was 174 billion
dollars (ADA, 2007). Therefore, diabetes and its complications is one of the leading
contributors to the annual cost of healthcare in the US (AHRQ, 2010). In addition,
cardiovascular disease and the resulting complications is the leading contributor to
the costs of diabetes (ADA, 2011: AHRQ, 2010).
Significance
Although clinical practice guidelines for the management of patients
diagnosed with diabetes are available for healthcare practitioners, a gap between
the prescribed standard of care, and achievement of process and outcome measures
exists (Nutting et. al 2007; National Committee of Quality Assurance (NCQA), 2011).
According to the ADA (2011), best performances are realized when individual
initiatives are “provided as components of a multifactor intervention and practices
utilize more of the chronic care model” (S 48). Dissemination of evidenced-based
guidelines alone can be unsuccessful in deeply influencing clinical practice (Allota et
al., 2008). System changes in addition to the use of guidelines are necessary to
achieve improved outcomes for the chronic care management of diabetes.
Healthcare for diabetes should also address the six areas identified from the
Institute of Medicine (IOM, 2001), which calls for care that should be safe, effective,
patient-centered, timely, efficient, and equitable. Specific to vulnerable populations,
care should not vary because of ethnicity, geographic location or socioeconomic
status (IOM, 2001).
Theoretical Framework
The Chronic Care Model
The Chronic Care Model (CCM), a systematic approach to the care of chronic
illness, has been used as a framework to guide chronic illness care, in replacing the
acute episodic, fragmented approach to care (Wagner, l998). The six components of
the CCM include: the health care organization, community resources, self-
management support, delivery system design, decision support, and clinical
information systems (Bodenheimer, Wagner, & Grumbach 2002a; Improving
Chronic Illness Care, 2006-2011). The model provides a guide for system changes
within ambulatory care practices to improve the quality of chronic illness care and
outcomes (Bodenheimer, Wagner, & Grumbach 2002a). The CCM has been used as a
quality improvement tool and model for comprehensive chronic illness care. Of
importance is the emphasis on collaboration between all team members to create
new and improved systems and procedures that support patients and providers in
the treatment and management of chronic illness (Kass, 2004).
Model for Improvement and Plan-Do-Study-Act
The Model for Improvement is a tool for accelerating quality improvement
and consists of two parts: the Improvement Model and the Plan, Do, Study, Act
(PDSA) (Institute for Healthcare Improvement (IHI, 2011). The PDSA is a cyclical
model for testing a change in a practice site and spreading the change on a larger
scale and then to other practice sites (IHI, 2011).
Health Resources and Service Administration (HRSA) Health Disparities
Collaboratives (HDCs)
The HRSA and the CDC’s Diabetes Prevention and Control Program partnered
together to sponsor the HDCs, with community health centers (CHCs) to improve
chronic illness care in minority and underserved groups of people and to reduce of
healthcare disparities. CHCs are safety net providers for low-income, uninsured and
ethnically and racially diverse groups of people (Kass, 2004). Goals established by
the HDCs for diabetes care are based on ADA guidelines, expert consultation, (Kass,
2004) and providers in the CHCs.
Purpose of Study
The purpose of this QI project was to create a sustainable QI program for
type-2 diabetes and subsequently other chronic disease management. Following the
implementation of the QI program, process and outcome measures for type-2
diabetics in a nurse-led safety net clinic were evaluated.
The research questions were as follows:
1. Does using a systematic approach with multifactor interventions
of care such as the CCM improve processes of care that are based
on evidence-based guidelines?
2. How will use of the CCM in a nurse practitioner led safety net clinic
support an ongoing quality improvement program?
The urban population for this safety net clinic is for individuals who are
underserved, underinsured, of lower socio-economic status, and of varied race and
ethnicity. Seventy-five percent of the clinic population is self-pay and 13 percent of
the population is covered by Medicaid. This population is often referred to as a
vulnerable population, which means that this population is at greater risk for health
problems and poorer outcomes (Institute for Nursing Centers, 2008). In 2000 the
Institute of Medicine (IOM) defined safety net providers as those who “organize and
deliver a significant level of health care to uninsured, Medicaid and other vulnerable
patients and offer access to services regardless of patient ability too pay” (p. 21).
Prior to the initiation of this QI project a formal QI program for diabetes or
other chronic disease management did not exist. Practice guidelines based on the
ADA standards of practice were listed on a chart form and all members of the team
contributed to the completion. Although care for diabetes and other chronic
illnesses had been comprehensive and inclusive of multiple components, it was not
systematic nor did it follow any particular model of care.
Review of Literature
The Chronic Care Model
The six CCM components identified previously serve to create system
changes in which “informed, activated patients interact with prepared, proactive
practice teams” (Bodenheimer et al., 2002a, p. 1775). Studies have shown that the
CCM improves the management of diabetes (Bodenheimer et al., 2002b). Studies
reviewed containing any of the components of the CCM model demonstrated
effectiveness in improving patient outcome measures and lowering costs for chronic
disease (Mackey, Cole, & Lindenberg, 2005). Those studies utilizing the self-
management component resulted in the most consistent improvement in process or
outcome measures (Bodenheimer et al., 2002a).
Collaborative breakthrough series and implementation with the CCM
improved clinical outcomes and care processes in an earlier study by Wagner et al.
(2001a). Recommendations based on review of the literature supported patientprovider interactions, diabetes care and self-management support among
underserved and minority populations, and implementation of chronic care
management systems for diabetes care (Glasgow et al., 2001). According to Nutting
et al (2007), greater practitioner use of the CCM was associated with higher patient
behavioral and clinical care composite scores, and lower HbgA1c when the primary
provider was a nurse practitioner. Similar findings were found when a chronic care
intervention group received significantly more recommended preventive services
and patient education than the non-intervention group (Wagner et al., 2001).
Another study demonstrated consistency with the CCM resulted in a reduction of
modifiable risk of coronary heart disease in patients who attended smaller clinics
(Parchman, Zeber, Romero, & Pugh 2007). Findings from a 2009 study, (Janson et
al.) suggests that care given by an inter-professional team instructed on utilization
of the CCM was effective in improving process and outcome measures for diabetes
care.
Chronic Care Model, Underserved and HRSA HDCs. It is the combination
of process and outcome measure sets and measurement in the context of systems
change that can result in high-leverage change for diabetes (Camp & Dethlefs, 2008).
These authors suggest that measurement for “quality improvement needs to fit into
a broader model of change, impact population level of care and impact point of
service care”(slide 13). They suggest with the CCM, the model for improvement, the
rapid cycle process, achievement of outcomes measures and the HDCs a reduction of
healthcare disparities should occur.
A study conducted by Chin et al. (2007) that used CHCs as a setting and the
HDCs for diabetes care, noted improvements in processes of care occurred rapidly,
however, the researchers noted it took four years before HbgA1c values decreased.
The investigators (Chin et al.,) suggested the importance of “enduring commitments
to the quality improvement interventions and long-term studies” (p.1142).
A systematic review conducted by Coleman, Austin, Brach, and Wagner
(2009), found that organizations with higher achievement of diabetes outcomes
were more likely to utilize the CCM. Coleman et al. (2009) reported the CCM
provided immediate process improvement with a delay in clinical outcomes, as well
as cost savings from improved disease outcomes. Results from another study
conducted by Piatt et al, (2006) improved clinical and behavioral outcomes for
diabetic outpatients, when implementing the CCM in an underserved population.
A study by Hicks et al., (2006) studied the quality of care for groups known to
receive low-quality care and found that the quality for CHCs was comparable to that
delivered in other practices that provide services for underserved population but
lower than documented care from commercial managed care organizations and the
Veterans Administration system. Disparities by race and ethnicity were eliminated
after adjustment for insurance status and it was also noted was that the HDCs might
have a positive disproportionate effect on the uninsured, since this group has the
greatest need for improvement. Findings from the initial Chronic Illness
Breakthrough Series (BTS) (Wagner et al., 2001a), also suggests larger
improvements were experienced by CHCs having the more challenging patient
population and scarcer resources.
Chronic Care Model and nurse practitioners. Several authors explored
the use of the CCM by NPs, especially those providing primary care to more
vulnerable patients or those in safety net clinics. Dancer and Courtney (2010)
encourage NPs to utilize evidence-based interventions that encompass each aspect
of chronic care with the CCM. They also suggest that understanding type-2 diabetes
management interventions within the CCM will enable the NP to more broadly
identify gaps, define needs, and design and implement new healthcare strategies to
improve patient outcomes. Dancer and Courtney (2010), and Fiandt (2007a, 2007b)
call for NPs to assume a greater leadership role to improve chronic disease care and
implement components of the CCM in their practices.
Boville et al., (2007) redesigned the nurse practitioner role in a practice
setting to include proactive management through planned visits, intensification of
treatment, collaboration with team members along with other components of the
CCM. After the role redesign, Boville et al. (2007) reported improved outcomes in
patient’s glycemic control, lipid management and hypertension control. Fiandt
(2007a) also maintains NPs need to take a leadership role in quality improvement
and practice efforts, as well as apply research skills to support complex and
comprehensive interventions.
Schram (2010) explored use of the CCM practice design for use with the
Medicare Medical Home Demonstration Project. In comparison to the patient-
centered medical home (PCMH), the CCM has provider-neutral language and also
adheres to IOM definition of primary care, thus allowing NPs to be primary care
providers. The author (Schram, 2010) also suggests the importance of meeting the
requirement for patient-centeredness and support of self-management to improve
outcomes.
Vulnerable Populations
Several sources identify characteristics of vulnerable populations, which can
assist in setting expected outcomes for quality improvements efforts. Participants
in the HRSA HDCs for diabetes quality improvement outcomes include safety net
practices from federally qualified health centers (FQHCs). These collaboratives
focus on underserved safety net populations, but these patients may be at less risk
for healthcare disparities than patients from nurse practitioner managed health
clinics (NMHCs).
Patients receiving care in NMHCs are less likely to have any form of
insurance (67%), more likely to have clinics in or near public housing units (38%),
and twenty-five percent of NMHCs address needs of homeless people (Institute for
Nursing Centers, 2008). The most frequently managed illnesses in NMHCs are
chronic diseases. Based on statistics from the Institute for Nursing Centers (2008)
patients are likely to be poor and represent varied ethnicity and most significantly
have no form of insurance, which may put them at greater risk for chronic disease
and poorer outcomes.
A group of investigators studied the characteristics of risk in patients of
NMHCs over a five year time period (Fiandt, Doeschot, & Lanning, 2010). Of great
importance is the finding that all NMHCs had a higher prevalence of very low
socioeconomic status and included many more uninsured people. The NMHCs had
the highest percentage of patients with diabetes. The findings of this study led the
investigators to recommend that NMHCs “collect data in a structured and
comprehensive way to document the complexity of patient needs, to determine
baseline information for improved outcomes, to guide population-specific
interventions, to demonstrate the impact of NPs and to inform payers and policy
makers” (Fiandt et. al., 2010, p.478).
Program Implementation
Six months prior to the beginning of the program, discussion at clinic staff
meetings included chronic disease population of inclusion, chronic care model,
HRSA collaboratives, and general principles of quality improvement. This project
was presented to the administration prior to the initiation of a four-month
retrospective audit for type 2 diabetes measures. The hospital organization has
Magnet recognition with strong support for advancing evidence-based practice and
improving patient outcomes. Support was also achieved from numerous other
hospital departments including the quality improvement and laboratory staff,
coding and technology support staff, and the nursing research committee.
The importance of teamwork and the value of each team member’s
contributions were reinforced at all encounters. Team members supported having
the CCM as the model to improve the care for patients with the goal of adding other
diabetes measures and eventually other chronic illnesses. Core process and outcome
measures and goals from the HRSA HDCs were adopted. The most important
emphasis prior to the start of the project was creating a culture for practice where
all team members valued providing care consistent with the CCM.
Immediately prior to the first ongoing data collection period there was
orientation to the Model for Improvement and the PDSA cycles for rapid
improvement. Bimonthly meetings for further staff education for both the CCM and
quality improvement occurred, with the first meeting of each month reviewing
results from the previous month’s chart reviews. There were on-going PDSA cycles
for selected interventions for improvement throughout this project. Staff education
provided an opportunity for staff with minimal background in the area of quality
improvement or models of care to not just learn, but also apply new approaches as
active participants along with patients to achieve better health outcomes.
Each of the components for the CCM was reviewed and possibilities for
change were determined. Initial focus on self-management support included
methods for engaging patients in their care with emphasis on how to support
patients with goal setting. Principles for motivational interviewing have recently
been included in staff meetings.
Delivery system design has occurred with some ease as the recent addition of
the initial stages of the EMR has supported positioning staff for better patient flow
and patient centeredness. All staff including practitioners, LPNs and MAs
participate in activities related to the accomplishment of diabetes standards of care.
From admission and throughout the visit, each staff encounter includes patient goal
assessment and evaluation of accomplishment of all standards of care.
Decision support has included coordinating activities with experts from the
hospital’s diabetes institute and increasing collaboration along with other diabetes
specialists. Six hour classes provided by the diabetes education department were
offered for minimal or no cost to our diabetics, funded by the hospital foundation.
Additional collaboration with the diabetes education department included working
jointly with patients for consistent and meaningful goal setting. Attendance by clinic
staff at the diabetes education classes increased awareness of content for
reinforcement and consistency of patient teaching. All staff attended some formal
diabetes education since identifying diabetes as an improvement project. Nurse
practitioners from the clinic along with the diabetes NP are jointly reviewing
standards of care for all areas related to the care of diabetes and its complications.
Collaboration with an endocrinologist along with regular discussion groups for both
clinic and diabetes NPs are currently in the development process. Chronic disease
evidence based best practices will be embedded with future phases of the EMR,
along with the capability for chronic disease registries.
Recent participation in the community’s Diabetes Alliance program has
identified opportunities in the community for our diabetics. There are ongoing
efforts to identify other community support opportunities.
In addition to bimonthly meetings, staff were given personalized packets
with information to support learning. Another motivating opportunity for staff
included participation in the Institute for Health Improvement’s (IHI) open
classroom, which gives staff further access to quality improvement process, safety,
and leadership for change information. The IHI provided scholarship for the open
classroom for the clinic staff. Administration approved paid time for staff to
complete the eighteen and one-half hour continuing education program. This not
only provided needed continuing education for our LPNs and MAs but also was very
motivational for them. They have been very engaged in this process and have
appreciated their significant roles as part of the team. Another IHI scholarship
provided for attendance at a conference on transforming care to improve patient
access and patient centeredness. Actual initiation of some of these interventions for
the program did not occur until towards the end of the three-month project period,
but are continuing to evolve. A constantly evolving effort continues to support the
purpose of implementing a sustainable QI program based on the CCM in a nurse led
safety net clinic
Methods for Quality Improvement Project
Staff and administrative support and the initial phase of staff education
preceded a retrospective assessment of use of select-evidenced based diabetes
clinical practice guidelines. Second, a process improvement was implemented using
select elements and related interventions of the Chronic Care Model, the Model for
Improvement, and the PDSA model.
Setting and Sample
Medical record audits were obtained from an urban inner city hospital-
based nurse-led safety net clinic determined by provider ICD9 coding of patients
who were diagnosed with type 2 diabetes at discharge for a four-month period prior
to the quality improvement effort. Medical record audits for three one-month
periods were obtained on all patients treated and discharged with ICD9 coding of
type 2 diabetes. Core diabetes process and outcome measures from the HDCs were
obtained from both the retrospective review and the ongoing medical record review
period (Table 1).
The staff employed at this clinic includes: l.6 FTEs family nurse practitioners,
1.6 FTEs licensed practical nurses, one FTE receptionist and one MA..
Consent
Institutional Review Board (IRB) approval was received.
Procedures for Data Collection
Charts were selected between the dates of December 1,2010 and March
31,2011 to determine historical attainment of diabetes process and outcome
measures for all patients with type 2 diabetes identified with the ICD 9 code of
250.00. Core measures from the HDCs utilized included outcome measures for
average HbgA1c, blood pressure reading and LDL values. Process measures
included documentation of self-management goals, prescription of aspirin, and the
number of HbgA1cs obtained three months apart over the last year.
Ongoing medical record reviews were completed on a monthly basis for
patients with appointments for diabetes care from June 1, 2011 to August 31, 2011.
All staff used a copy of the diabetes core measure flow sheet in addition to the usual
diabetic standards of practice flow sheet for all patients registered for appointments
for type two-diabetes. Any patients during the on-going three-month quality
improvement project having laboratory testing for HbgA1C with results of 6.6 or
greater were scheduled for a diabetes follow-up visit (ADA, 2011). If this follow-up
office visit occurred during the three-month data collection time period, they were
then included in this improvement project. The diabetes flow sheet will be
maintained for sustained quality improvement of diabetes patients, until the final
phase of the hospital system electronic medical record is fully operative with
registry capabilities. Outcomes were reviewed with the quality improvement team
following each month of the audit periods.
Analysis
Descriptive statistics were used to analyze the data.
Outcomes
A retrospective review of 105 patient’s medical records was completed. On-
going medical record reviews were obtained for the month of June (n=35), July
(n=25) and August (n=30). All core processes of care improved each month of the
three-month ongoing QI improvement project and compared to the retrospective
data as shown in Table 1. The area of most noted improvement was the attainment
of patient established self-management goals, reflecting the area of most intense
staff focus.
Lessons Learned
Although achievement of process measures of care improved over time,
outcome measures for this time period were reflective of only one measurement per
patient. Since most diabetics have one visit every three months, the data collection
over the three one-month periods in total was reflective of one cycle of visits for the
clinic diabetic population. Thus this measurement would not be the result of any
intervention. The measurement of process attainment was realized over a three-
month period of time, but a longer study period would have given a more sustained
result, and provided an opportunity to examine the initial impact on outcome
measures.
Discussion
Results were consistent with studies showing that processes of care can
occur quickly, although a longer period of time is required for meeting benchmarks
for outcome measures (Allota et al., 2008; Chin et al., 2007).
A recommendation for the future includes the utilization of a chronic care
assessment tool by staff and patients to measure the consistency of care with the
CCM. Improvement over time could be used to evaluate the degree of a chronic
illness care culture.
Implications for Nursing Practice
Nurse practitioners providing care in safety net clinics are well prepared to
provide for the complex needs of patients with diabetes and to impact policy on
behalf of the needs of those most vulnerable to the development of diabetes and the
long-term complications. The CCM is foundational to the patient-centered medical
home, which has emerged most recently as a model to provide better outcomes and
reduce disparities for people with chronic diseases. Thus, the use of the CCM can
position nurse practitioner led clinics for future PCMH model utilization, especially
in those states that currently do not have full independent scope of practice.
Futuristically, nurse practitioner led clinics can benefit from the financial incentives
of achieving PCMH recognition by the National Committee of Quality Assurance
(NCQA), and attain needed financial sustainability and reduce health care disparities
(Duderstadt, 2008: Institute for Nursing Centers, 2008).
Conclusion
This diabetes quality improvement project in a nurse practitioner–led safety
net clinic utilizing the CCM was effective in improving processes of care and in
developing a sustainable and ongoing quality improvement program. This gradual
transformation of care delivery in the context of a systems change was
accomplished utilizing a multifaceted approach. Although this clinic is engaged in
the earliest stages of transforming the culture for the delivery of chronic illness care
with limited staff and resources, it serves as the foundation for sustained chronic
care development and quality improvement.
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